Instructions for Part I - General Plan Information

1. Plan Sponsor Information

a–g – Report the name and address of the Plan Sponsor. If either has changed since your last filing, check the box to report that fact.

h Business Code – Report the six-digit code that best describes the nature of the employer’s business. If more than one employer is involved, report the business code for the predominant business activity of all employers. A list of business codes is included in Appendix 4.

i CUSIP number – If a CUSIP number has been assigned to publicly traded securities of the Plan Sponsor or any member of the Plan Sponsor’s controlled group, report the first six digits of the CUSIP number. Otherwise, leave this item blank.

A CUSIP number is a nine-digit number assigned to the publicly traded securities of a Plan Sponsor (or member of the Plan Sponsor’s controlled group) under the securities numbering system of the Committee on Uniform Securities Identification Procedures. The first six digits of the CUSIP number identify the securities issuer, the next two digits identify the specific securities issue, and the last digit is a check digit.

2. Plan administrator information

Report the name and address of the Plan Administrator. Note that this is the address where we send official correspondence to the plan (e.g., an invoice for late payment charges). To keep our records current and enable us to send correspondence to the correct address, you should inform us of address changes as soon as they occur. You may do so by contacting us either in writing or by e‑mail. See Appendix 2 for contact information.

If the Plan Administrator’s name and address is the same as that of the Plan Sponsor, you may satisfy this requirement by checking the box to report that fact.

If the Plan Administrator’s name or address has changed since your last filing, check the box to report that fact (even if you informed us of the change prior to submitting this filing).

3. Plan information

a Plan name – Report the complete name of the plan as stated in the plan document. For example, "The ABC Company Pension Plan for Salaried Personnel."

b Premium Payment Year information

1. Report the date the Premium Payment Year commences and the date it ends. If you are filing for the first year of a New Plan, the Premium Payment Year commencement date ("PYC") should generally be the plan effective date.

2. If the plan year commencement date has changed since the most recent PBGC filing as a result of a plan amendment changing the plan year, enter the adoption date of the plan year change.

3. Check the box if plan qualifies to pay a prorated premium for this Premium Payment Year. A plan qualifies to pay a prorated premium only if the Premium Payment Year is:
   • a short first year of a New or Newly-covered Plan;
   • a short year created by an amendment that changes the plan year (but note that an amendment is not considered to change the plan year if the plan merges into or consolidates with another plan or otherwise ceases its independent existence either during the short plan year or at the beginning of the full plan year following the short plan year);
   • a short year created by distribution of plan assets pursuant to plan termination; or
   • a short year created by the appointment of a trustee for a Single-employer Plan under ERISA section 4042.

   There is no premium proration where a plan ceases to be a covered plan before the end of the plan year.

   Note that the short year need not have ended by the time you pay a prorated premium, but if the plan year turns out to be longer than you anticipated, you will have to make up any premium underpayment, which will be subject to interest and penalties.

   Note also that premium proration is not available for "overlapping" premium payments resulting from a plan merger, consolidation, or spinoff.

c Employer Identification Number (EIN) and Plan Number (PN) information

1. Report the 9-digit EIN of the Plan Sponsor and the 3-digit PN of the plan.
2. If the EIN and PN for this filing do not both match exactly the EIN and PN reported in the most recent premium filing, report both the EIN and PN that were reported in the most recent premium filing. If this is the first premium filing for this plan, leave this item blank.

   Please note the following exceptions that apply only if this is an amended filing:

   • If item 3c(2) was reported incorrectly in the original filing (i.e., the filing that is being amended), provide the correct information in the amended filing,
   • If item 3c(2) was reported correctly in the original filing, provide the same information in the amended filing.
3. If the EIN and PN for this filing do not both match exactly the EIN and PN reported in the 2010 Form 5500, report both the EIN and PN that were reported in the 2010 Form 5500, and attach an explanation. If a 2010 Form 5500 was not required, leave this item blank.

d Plan type – Indicate whether the plan is a Multiemployer Plan or a Single-employer Plan.

e Plan size – Premium due dates vary based on whether the plan is classified as a Small Plan, Mid-Size Plan, or Large Plan. Indicate which Plan-Size classification applies for the Premium Payment Year. Note that this classification is based on the Participant Count for the prior plan year (i.e., the number of participants for whom a Flat-rate Premium was owed for the prior year). If this is a New Plan or a Newly-covered Plan, check the "N/A; first filing" box (and be sure to complete item 14 — additional information for New Plans and Newly Covered Plans).

4 Plan contact

Report the name and phone number of the person we may contact if we have any questions concerning this filing. If this person has an e-mail address, report that e-mail address. If the filing is completed by a plan consultant, you may report the consultant’s identifying information.